Va. DMAS Hospice Provider Manual ch. IV, Admission Criteria For Covered Hospice Services

The following applies to Fee-for-Service (FFS) and MCO determinations. In order to

be eligible for hospice care under Medicaid, an individual must be certified as terminally

ill. An individual is considered terminally ill if his or her life expectancy is six months or

less, if the terminal illness runs its normal course. In addition, the individual or, in cases

where a representative has signed the election statement, his or her representative, must

have knowledge of the illness and life expectancy and must elect to receive hospice

services, rather than active treatment for the illness. Both the attending physician and

the hospice medical director, or physician member of the interdisciplinary team, must

certify life expectancy. The hospice benefit period begins with the date of the

individual/representative signature on the hospice election statement. A representative

is defined as a person who is, because of the individual’s mental or physical incapacity,

authorized in accordance with state law to execute or revoke an election for hospice care,

or to terminate medical care on behalf of the individual who is enrolling hospice.

Hospice must obtain certification an individual is terminally ill in accordance with the

following procedures:

For the initial 90-day benefit period of hospice coverage, a written certification

documented on page 2 of the Request for Hospice Benefits form (DMAS 420) must be

signed and dated by the attending physician and hospice medical director. (NOTE: For

directions on how to access the current version of this form, please refer to the last section

of this chapter, titled “How to Access DMAS Hospice Forms.”) This initial certification

must be obtained prior to the request for authorization of enrollment. For individuals who

are dually eligible (Medicare/Medicaid), Medicaid will accept the Medicare certification

period(s) signed by both physicians (the attending physician and the hospice medical

director) within the required Medicare time frames. This will apply even when the

individual becomes Medicare eligible after a period when Medicaid was the primary payer

for hospice services. Hospice services cannot begin prior to the individual’s election of

the hospice benefit. This certification must be maintained in the individual’s medical

record.

DMAS will accept the Medicare definition and regulations regarding the “Certification of

Terminal Illness” as cited in the Code of Federal Regulations at 418.22(a)(2) and (3),

which read as follows:

“a) Timing of certification -- (1) General rule. The Hospice must obtain written

certification of terminal illness for each of the periods listed in §418.21, even if a

single election continues in effect for an unlimited number of periods, as provided

in §418.24(c).

(2) Basic requirement. Except as provided in paragraph (a)(3) of this

section, the Hospice must obtain the written certification before it submits a

claim for payment.

(3) Exceptions. (i) If the Hospice cannot obtain the written certification within

2 calendar days, after a period begins, it must obtain an oral certification

within 2 calendar days and the written certification before it submits a claim

for payment.”

For any subsequent 90-day or 60-day hospice period, Section IV: Notice of Re-Election

of Hospice Benefit of the Request for Hospice Benefits form (DMAS 420) or a Physician

Recertification form (DMAS 420A), must be signed and dated by the medical director of

the hospice, or the physician member of the hospice interdisciplinary team, on or before

the beginning day of the 90-day or 60-day period. (NOTE: For directions on how to

access the current version of this form, please refer to the last section of this chapter,

titled “How to Access DMAS Hospice Forms.”) This certification must include a statement

that the individual’s medical prognosis (his or her life expectancy) is six months or less, if

the illness runs its normal course.

If hospice cannot obtain the written recertification within two (2) calendar days after the

recertification period begins, it must obtain an oral recertification within two (2) calendar

days and the written recertification prior to submission of a claim for payment.

Documentation must be in the chart that the provider received oral recertification and the

date that recertification was received. This recertification must be maintained in the

individual’s medical record.

In cases of Medicaid retroactive eligibility, the requirements listed above still apply.